Evaluation of Epiphora

Abstract

Epiphora or watering is one of the most common symptoms of any ocular pathology. Though most cases of watering are due to nonpatency in the lacrimal outflow pathway, others like eyelid and adnexal disorders, corneal and ocular surface pathology can also manifest as watering. In this context, it is important to distinguish between the terms epiphora and pseudoepiphora or hyperlacrimation [1, 2]. True epiphora refers to watering due to obstruction in the lacrimal outflow pathway, while hyerlacrimation refers to excessive watering due to reflex irritation of the corneal and conjunctival surface as in cases of dry eye, corneal abrasion, corneal foreign body, etc. (Fig. 6.1a–f). It is also important to differentiate between anatomical and functional lacrimal pathway obstruction. Anatomical obstruction refers to any structural pathology in the lacrimal outflow pathway which hinders tear drainage. Conditions like punctal and canalicular stenosis and block, nasolacrimal duct obstruction (NLDO), etc., are the causes of anatomical obstruction. In functional dysfunction, the lacrimal outflow pathway is normal anatomically with a patent syringing. However, there is a failure of the lacrimal pump mechanisms which could be due to pathology outside the lacrimal pathway like punctal ectropion, eyelid laxity, or due to problems in the lacrimal pump mechanism itself as in cases of facial palsy. Hence, a detailed and comprehensive evaluation is needed to identify the cause of watering and initiate appropriate management. The goal of the evaluation is to differentiate true epiphora from hyperlacrimation, differentiate obstructive cause of epiphora from nonobstructive cause, and find the site of obstruction in cases of obstructive epiphora. The evaluation can be divided into history taking, local examination, lacrimal system vital signs, ancillary investigations, and nasal evaluation.